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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 t,Stockton,CA 9520 -3029 <br /> Telephoner (209)468-3420 FaxMain -(209)468-3433 Web.2www.8' ov.or eh <br /> d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnY MINOR violations noted in the "Notice to Comply"in the attached inspection report must be <br /> corrected within 3_ 0 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health.Department(EHD) address at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 60 <br /> unless otherwise specified in the IR. da s <br /> For this Certification to be complete the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Operator's certification <br /> Inspection Date: e l 7 R Inspected By: �J <br /> Facility Address: , & ey�/•EPA ID#: <br /> I certify,under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Title: i <br /> Signature: ! Date: <br /> EHD 22-02-005 Rev 05/07 <br />